Healthcare Provider Details

I. General information

NPI: 1982730438
Provider Name (Legal Business Name): JERRY STOVALL L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 OLD EUREKA WAY
REDDING CA
96001-0336
US

IV. Provider business mailing address

2485 OLD EUREKA WAY
REDDING CA
96001-0336
US

V. Phone/Fax

Practice location:
  • Phone: 530-242-8971
  • Fax: 530-244-1546
Mailing address:
  • Phone: 530-242-8971
  • Fax: 530-244-1546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS16319
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: